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Parastomal Hernia
Agneta Montgomery
44
44.1 Introduction
An enterostomy is necessary when continuity of the gastrointestinal tract cannot be preserved for different reasons
or if deviation of urine is needed using an ileal conduit. To
have a stoma “per se” results in a reduced quality of life
(QoL) [1]. Around 800,000 in the USA and 100,000 in the
UK live with a stoma. Generalizing, it means that around
0.15 % of the western population lives with a stoma.
Around half of all these patients will have a permanent
stoma [2].
A parastomal hernia (PH) is the most commonly seen
complication in association with a stoma and frequency is
reported to vary widely between 10 and 70 % depending on
technique used and time for follow-up. The incidence is
estimated to be over 30 % by 12 months, 40 % by 2 years
and 50 % at longer duration of follow-up. Operative factors
might have an impact on function of the stoma such as
leakage, prolapse of the stoma, skin erosion, swelling and
pain that can all reduce QoL substantially and cause high
costs for society.
The first stoma in “modern” time was performed by
Allingham in 1887 operating a patient with a rectal obstruction deviating colon by fixating the mesocolon by sutures to
the skin [3]. Techniques have evolved over time and today
there seems to be consensus using mesh techniques for
parastomal hernia repair. The introduction of a prophylactic
mesh, when creating a stoma, give new hope for patients
that would need a permanent stoma with the potential of
improved QoL.
A. Montgomery, M.D., Ph.D. (*)
Department of Surgery, Skåne University Hospital,
205 02 Malmö, Sweden
e-mail: agneta.montgomery@skane.se
44.2 Diagnose and Incidence
A parastomal hernia is an incisional hernia protruding
through the trephine were the intestinal loop runs [2]. It
could either be the stoma loop, another intestinal loop or the
omentum that protrudes.
There is no consensus on how to define, diagnose or how
to report on PH rates. Clinical examination upon Valsalva
manoeuvre is one suggested method for diagnose and most
commonly probably a bulging, reducible or not, is also
defined as a PH. Radiologists define a herniation as any
intra-abdominal content protruding beyond the peritoneum
or the presence of a hernia sac.
Several classifications have been introduced, but none
have been used in a clinical setting as a tool for choosing an
operative technique or for measuring outcome after PH surgery. There are mainly three historical classifications
(Devlin, Rubin, Moreno-Matias), based on either intraoperative findings or radiological descriptions,’ that have rarely
been used in scientific papers. The European Hernia Society
has made a suggestion of a classification, presented in a grid
format, Fig. 44.1 [4]. It was developed with the aim to be
used as a standard to compare results between studies. It has
not yet been validated, but used in several studies. The classification takes into account some of the important risk factors for a recurrence like hernia defect size, concomitant
incisional hernia and primary or recurrent procedure.
Computed tomography (CT) in a prone position is the
most commonly used investigation for PH diagnose, Fig. 44.2.
A better accuracy for diagnose was demonstrated when using
a supine position at CT and can be recommended especially
in unclear cases [5]. Three-dimensional ultrasonography (3D)
through the stoma is a promising alternative to CT scanning
to distinguish a bulge from a parastomal hernia [6].
The overall incidence of parastomal hernia is approximately 50 % for an end colostomy and 30 % for an end ileostomy at 10 years [7]. The difference between an ileostomy
and a colostomy is suggested to be dependent on the difference
© Springer International Publishing Switzerland 2017
W.W. Hope et al. (eds.), Textbook of Hernia, DOI 10.1007/978-3-319-43045-4_44
345
346
Fig. 44.1 EHS grid for classification of parastomal hernias
(Reproduced from Śmietański M, Szczepkowski M, Alexandre JA,
Berger D, Bury K, Conze J, et al. European Hernia Society classification of parastomal hernias. Hernia. 2014;18(1):1–6. doi: 10.1007/
s10029-013-1162-z [4])
in the size of the trephine. When comparing clinical
investigation to CT investigation in 108 colostomy patients,
with a follow- up of 25 months, 27 % respective 33 % were
reported to have a parastomal hernia, indicating clinical diagnose to be fairly accurate [8]. In another study the prevalence
of PH was 46 % in conjunction with sigmoid colostomy and
22 % at ileostomy [9]. In a register based study including
almost 500 patients the risk of having a symptomatic PH 3
years after surgery was 11 % [10].
A. Montgomery
44.3 Symptoms, Patient Information and Risk Factors
A stoma per se can result in several inconveniences and psychological problems wearing certain clothes, fear of being in
official places due to unexpected incidents of stoma leakage
and flatulence, isolation from social networking and singles
may be reluctant looking for a partner. Physical symptoms
are abdominal pain, pain around the stoma area, leakage due
to difficulties in fitting of the osteomy dressing, skin erosions, stoma prolapse, stoma orifices obstruction (Fig. 44.3),
a siphon of the intestinal loop subcutaneously with emptying
problems and a parastomal hernia, Fig. 44.4.
The parastomal hernia per se might not give any symptoms, but many patients complain on the swelling that the
hernia causes resulting in an asymmetric body image. A lot of
patients do not have the knowledge on the construction of the
stoma. The intestinal mesentery has to accompany the intestine through the abdominal wall, taking quite some space,
especially in patient with an elevated BMI. All stoma patients
are entitled to have a thorough description on how the stoma
is anatomically constructed and what expectations to have
Fig. 44.2 CT scan of a patient with a colostomy that is placed well
above the arcuate line, but a little bit too lateral through the rectal muscle with tendency of showing a kinked path subcutaneosly, but with a
perfect size of trephine on 2.5 × 3.0 cm. No subcutaneous siphon, parastomal hernia or prolapse is seen
from the cosmetic and functional point of view, either without
or with a potential complication. The patient is also entitled to
have a specially trained ostomy care nurse for regular appointments and available for consultation when needed.
Risk factors to develop a parastomal hernia, when having
and end-colostomy, are female gender, enlarged aperture and
age, reported in a study of 108 patients [8]. Respiratory comorbidity, elevated BMI, elevated waist circumference, other associated abdominal hernias, ascites, corticosteroid use, and
postoperative sepsis are risk factors reported in other studies
[11]. An aperture size of <2.5 cm for a permanent stoma seems
to lower the incidence of having a PH hernia reported in a CT
scan study [12]. In another study the aperture size and patient
age were independently predictive factors of PH development;
44 Parastomal Hernia
Fig. 44.3 Patient having a parastomal hernia, a stoma prolapse and an
associated incisional hernia in the umbilical region at the same time
Fig. 44.4 Stricture in the stoma orifice
for every millimetre increase in aperture size, the risk of developing a hernia increased by 10 % and for every additional year
of age, the risk of developing a hernia increased by 4 % [9]. In
a register based study it is concluded that the emergency setting
was the strongest risk factor for death [13].
The largest risk factor for having a PH is probably the
surgeon crating the stoma. The surgeon should be aware of
the risk factors of having a PH, were to get the most perfect
location for every single patient and to use the best technique
to bring the intestine out through the abdominal wall.
44.4 Quality of Life and Indications
for Surgery
Patients having a stoma per se might suffer from a poor QoL
that would be potentially worse when having a PH. A quality
of life questionnaire was developed using 20 specific ques-
347
Table 44.1 Stoma symptoms based on frequency and severity together
with “acceptance in daily life” based on a Swedish enquiry study in 495
stoma patients 3 years after abdominoperineal excision for rectal
cancer
Total in % (minor/severe)
Diarrhoea 33 (29/4)
Leakage 43 (41/2)
Loud flatulence 80 (50/30)
Smelly flatulence 50 (42/8)
Skin irritation 39 (37/2)
Stoma care problems 10 (9/1)
Can live a full life 94
Feel at ease with stoma 92
Worries that something awkward may
occur during sexual activity
Feel dirty and unclean 35
Have the leisure activities and the social
life as wanted
Median age was 66 years (Martinez-16 [10])
18
91
tions, each being graded on a four level scale, and summarized in as “Stoma-QoL score”. This score was significantly
reduced in patients having a PH compared to patient without
a hernia [14].
An enquiry based study from the Swedish colorectal register was performed, based on 495 rectal cancer operated
patient having a stoma with no PH in 89 %, with a follow-up
of median 3 years after surgery [10]. Surprisingly high numbers with around 90 % report on not feeling any reduction in
QoL due to their stoma. Stoma-related symptoms are
reported in Table 44.1.
Surgery is of course mandatory in emergency cases with a
strangulated bowel within the hernia sack. In a case series of
consecutively operated PHs, 10 % were operated in an emergency setting that was associated with a high mortality rate
of 29 % [15]. No mortalities were seen in elective PH repairs.
Patients having no or mild symptoms due to a PH is not
recommended for operation since the risk of having a recurrence is high. In patients with old age, having a cancer recurrence or several risk factors are recommended for
conservative treatment. A well-designed support belt could
in some instances be recommended. In patients having poor
quality of life with recurrent pain, obstruction symptoms,
consistent episodes of leakage and skin problems as a cause
of recurrence would be considered as indication for surgery.
44.5 How to Perform a Stoma and Stoma
Types
The patients should be preoperatively marked for the ideal
position on the skin that should be thoroughly discussed with
the patient. Due to former scars or skin problems the most
ideal place should be used. If the patient has a transverse scar
from a flank or a subcostal incision, this side should be
348
A. Montgomery
avoided. These incisions usually result in several intercostal
nerve injuries with an adjacent atrophy of the rectal muscle
on the affected side. This would japerdice the support of the
stoma in the abdominal wall.
The most commonly used place of a stoma is through the
rectus muscle above the arcuate line in order to get as much
collagen support around the trephine as possible, as shown in
Fig. 44.5a. One should be aware not to harm the inferior epigastric vessels when planning the route through the rectal
muscle. Full blood supply is needed for muscle strength. It
could sometimes be difficult to get a straight way through all
the layers of the abdominal wall; posterior and frontal rectal
fascia and skin. A kinked path through the abdominal wall
could cause outlet obstruction. It is wise to use clamps to
medialize the fascia at the laparotomy to the midline when
preparing the route through the wall. The size of the trephine
for a colostomy is recommended to be <3 cm in diameter
[12]. In order to hopefully reduce the chance of another intestine to pass beside the stoma intestine, or to have a subcutaneous siphon of stoma intestine, the trephine edges of fascia can
be sutured to the stoma intestine. There is though no evidence
to support that this would reduce the risk of having a PH hernia, but on the other had the risk of harm is low. It is also wise
to pass your index finger through the stoma after finishing the
operation when wound is covered. You have the possibility to
redo the route if deemed necessary.
Sometimes the stoma “happens” to be placed too lateral
and/or low and will end up close to the semilunar line and
sometimes also below the arcuate line according to
Fig. 44.5b. This localization might be suboptimal.
A stoma can also be placed through a lateral position. A
Cochrane report concluded, based on >700 patients comparing stoma placement, either through or lateral to the rectus
abdominis muscle, that no robust conclusions could be
drawn due to poor quality of included studies. In conclusion,
the Cochrane review reported neither a difference in terms of
PH or stomal prolapse frequencies between the two routes
[16]. Stoma formation through the rectus muscle is though
the recommended method of choice. There are no evidences
that alternative routes are more favourable.
Both loop and end stomas from either the small intestine
or the colon are performed. The loop stoma of the terminal
part of the ileum or the sigmoid colon is commonly used as a
temporary stoma in an emergency setting in intestinal
obstructions at different levels, anastomotic leakages or other
causes of peritonitis. These are usually to be reversed within
3 months when problem is solved and patient is back in good
health. In very old patients, severe comorbidities or spread
cancer patients would often end up not having any reversal
procedure performed. Permanent stomas are usually due to
malignancy or inflammatory bowel diseases. An ileal conduit
is the most commonly used diversions after radical cystectomy. It is constructed using a segment of the ilium, a short
distance from the valve of Bauhini, into which the urethras
are implanted. Various types of nipples have been constructed for repeated catheterization instead of having an
ordinary stoma bandage [17].
44.6 Treatment Options and Outcomes
The fascial suture repair is largely abandoned due to recurrence rates exceeding 50–70 %. In a meta-analysis comparing suture repair to mesh repair resulted in a significantly
increased odds ratio (OR) for a recurrence of 8.9 compared
to a mesh repair [18]. A relocation of the stoma could be
considered on special situations, where the abdominal wall is
too damaged to be used, when repairing a recurrence of a
Fig. 44.5 (a) Ideal position of the stoma
through the rectal muscle with support of
both a posterior and frontal rectus sheet with
a straight way through all abdominal wall
layers. (b) Stoma in the wrong position
placed in semilunar line below the arcuate
line close to the epigastric vessels with the
potential risk of being damaged
44 Parastomal Hernia
349
PH. By relocation you could lower the risk of a PH using a
prophylactic mesh, but you add a laparotomy as a further
risk. You also have a higher risk of having an incisional hernia
at the old stoma site [11]. Fascial suture repair and relocation
is generally not recommended. A mesh is generally recommended for all repairs.
Surgical techniques for parastomal hernias repair are
reported by Hansson et al. [19]. Any position of the mesh in
the abdominal wall seems to work quite well.
The onlay technique was first described by Rosin and
Bonardi in 1977 [20]. This technique showed a surgical site
infection rate of 13 % and an overall mesh infection rate of
3 % with mesh removals necessary in almost all. This technique seems to have the highest recurrence rate of mesh
techniques and is seldom reported on the last years.
Retromuscular repair, usually via a laparotomy using a
keyhole technique, demonstrated 4.8 % wound infections, no
mesh infections and an overall recurrence rate of 6.9 % [19].
Intra-peritoneal techniques can be performed both open
or laparoscopically. The open intra-peritoneal mesh repair is
quite sparsely reported on since the laparoscopic technique
was introduced. The Keyhole and Sugarbaker techniques are
shown in Fig. 44.6a, b. The laparoscopic technique uses
three to four trocars. Adhesiolysis and reduction of the hernia sac content is performed. An advantage is that the
abdominal wall is expanded by gas insufflation, creating a
dome that would ease the placement of the mesh with a minimum of wrinkles.
The keyhole technique uses a mesh with a circular hole
(without or with a collar) with a slit so that the stoma can be
surrounded, Fig. 44.6a. The mesh is fixated thoroughly to the
abdominal wall. The Sugarbaker technique was first
described in 1985 were the intestine is lateralized and a mesh
is put intra-peritoneal covering the defect and the intestine
that runs lateral in a tunnel [21]. A e-PTFE prosthesis
anchored by trans-fascial sutures were used.
The laparoscopic Sugarbaker had significantly less
recurrences compared to the keyhole technique (OR 2.3).
The overall morbidity and mesh infection rate was 3 % and
comparable between techniques [19]. The most resent metaanalysis of laparoscopic hernia repairs including 469 patients
reported an overall recurrence rate of 17 % [22]. The
Sugarbaker technique showed 10 % and the keyhole 30 %
recurrences. Surgical site infection was seen in 3.8 %, reoperation due to obstruction in 1.7 % and other complications
in 16.6 % with no difference between techniques. Six mortalities were reported on postoperatively. The Sugarbaker is
the preferred technique compared to a keyhole technique for
laparoscopic parastomal hernia repair.
The Sandwich technique is described and presented by
Berger, the only one reporting on this technique, showing
very good results [23]. A double layer of PVDF mesh was
used. First a keyhole flat mesh, including a collar of mesh
around the intestine passing through the abdominal wall, followed by a Sugarbaker placed second mesh. Iatrogenic
bowel lesions were reported in 4 %, over all morbidity in
17 %, wound infections in 3 % and mesh infections also in
3 %. Only 2 % recurrences were reported after almost 2
years. Of the laparoscopic techniques the Sugarbaker is suggested as the preferred parastomal hernia repair in terms of
recurrence.
A review, including five RTCs and seven non-randomized
studies on a temporary ileostomy and colostomy after a low
anterior resection for rectal cancer, comparing the postoperative complications and investigating type of stoma to be preferred [24]. A lower risk of stoma prolapse and wound
Fig. 44.6 (a) Principles of the keyhole technique seen from the abdominal side. (b) Principles of the Sugarbaker technique seen from the abdomi-
nal side
350
A. Montgomery
infection was seen for the temporary ileostomy. It has a
minor impact on the patient’s QoL compared to a colostomy
and can be recommended as a temporary stoma to be used.
44.7 Mesh Types
A long list of meshes available for parastomal hernia repairs
are given by Gillern et al. Polypropylene mesh is the most
commonly used mesh in open surgery with good ingrowth
properties [25]. A major inflammatory response is seen that
could cause severe adhesions if placed intra-abdominally.
Erosions into the stoma, when mesh is cut and put around the
stoma, have also been reported on. Intra-abdominally the
polytetrafluoroethylene (e-PTFE) composite mesh has been
widely used to prevent adhesions. It was introduced already
in 1993. The ingrowth capacity on the abdominal wall side is
less and a thorough fixation is advocated in order not to
detach and cause a recurrence. The fixation is known to
cause postoperative pain that could be severe for the first
days. The e-PTFE mesh is better tolerated and gives a less
risk of erosion into the surrounding organs. A special polyvinylidene fluoride, PVDF [23, 26], mesh has also been
lounged for both retromuscular and intra-peritoneal use for
parastomal hernias. This material is more inert, with large
pores, have antiadhesive properties and have a strong reinforcement capacity. It has up today no FDA approval but is
widely used for incisional hernia surgery in Europe.
There are several composite meshes on the market that try
to combine the properties of integration into the abdominal
wall and a non-sticky side facing the intestinal side. There
are several different antiadhesive coatings lounged to cover
the intestinal side of the mesh, usually being low weight
polypropylene or polyester.
Several meshes are specifically manufactured, with a
stove-like tunnel around the stoma intestine, for either prophylaxis or treatment of a parastomal hernia. These type of
meshes are designed for either intra-abdominal, retromuscular or onlay positions. A 3D funnel PVDF mesh with a preformed circular hole, with a collar that would run along
with the intestine has been lounged in order to minimize
the risk of a recurrence when using the keyhole technique
by getting a more robust support around the trephine. The
risk of having an erosion into the intestine by the mesh
edge using a keyhole mesh for prophylaxis is also minimized [15].
44.8 Prevention of Parastomal Hernia
Since the recurrence rate after PH repair is high, the best
strategy would be to limit the risk of having a recurrence by
using a prophylactic mesh.
Prophylactic reinforcement of the stoma trephine reduces the
hernia rate to approximately 15 % [12]. If having a hernia after
the reinforcement it is likely to be of minor magnitude, resulting
in a decrease in the rate of hernia being symptomatic and in
need of surgery. If having a recurrence after an already reinforced
abdominal wall it might though be a more “tricky” operation.
Generally in hernia surgery a recommendation is to use an
untouched area or space when dealing with a recurrence.
In a meta-analysis by Shabbir et al. comparing prophylactic mesh to no mesh, three RTCs including a total of 128
patients (mesh 64, no mesh 64) with a follow-up between 12
and 83 months were included [27]. The incidence of PH in
the mesh group was 12.5 % compared with 53 % in the control group (P < 0.0001) diagnosed mainly on CT. A biologic
mesh (Permacol) was used in ten patients with no recurrence
after 6.5 months follow-up. There was no difference in meshrelated morbidity between techniques.
The frequency of PH after an ileal conduits using a prophylactic mesh has been studied in 114 patients using a
large-pore, lightweight mesh. Eight patients (14 %) had a PH
comparable to the results for colostomies. No associate complications were seen. RCTs are ongoing.
A prophylactic mesh has been proved to be cost effective
in stage I to III rectal cancer patients, but not for stage IV
[28]. A prophylactic mesh is recommended.
A prophylactic mesh is safe and is recommended to be
used in the creation of both a colostomy and ileostomy/ileal
conduit to reduce the frequency of PHs and thereby costs for
society.
44.9 Summary
A parastomal hernia is a “complication” or rather an
expected result when creating a permanent artificial route
and orifice for faecal or urine deviation through the abdominal wall in patients usually suffering from a cancer or a
chronic intestinal or bladder disease. Half of all stomas created are used for deviation during a limited time period,
were a PH might be of less importance. For further knowledge there are two resent nice review articles by Hotouras
et al. and Aquina et al. on the topic that summarizes and
highlights the persisting and growing challenges of PHs that
can be recommended [11, 12].
The colorectal surgeon or urologist performing the
large operation removing a cancer would operate for several hours and sometime a whole day for resection. You
cannot at this stage expect to always keep the full attention and energy to make a meticulous operation in creating
a perfect stoma. It might be wise to bring in a “fresh”
abdominal wall surgeon to perform the stoma creation,
taking care of all the details and consider using a prophylactic mesh.
44 Parastomal Hernia
351
A parastomal hernia is the single most common complication, resulting in a further reduced QoL, in patients that
already bears the burden of suffering from the primary cause
of having the stoma. Let us do everything in our power to
reduce this burden.
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use of prophylactic mesh during primary stoma formation to prevent parastomal hernia formation. Colorectal Dis. 2012;14(8):931–
6. doi:10.1111/j.1463-1318.2011.02835.x.
28. Lee L, Saleem A, Landry T, Latimer E, Chaudhury P, Feldman LS.
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2013.09.01.
Progressive Preoperative Pneumoperitoneum (PPP)
Adriana Hernández López, Estefanía J. Villalobos Rubalcava,
and Adrian Murillo Zolezzi
45.1 Introduction
The functions of the abdominal wall are: visceral retention
and protection, active participation in performing core
movements, aids in defecation and urination, and regulation
of the diaphragmatic movements for adequate pulmonary
function.
During embryological development the abdominal viscera enter and expand the cavity, such that it adjusts to its
newly acquired visceral content; because of its dynamic
nature and constant response to change it exerts low pressure
on the intra-abdominal viscera.
The capacity of the abdominal cavity varies according to
the volume and content. In pregnancy or ascites, the abdominal wall gradually distends increasing the ability to contain
the new content.
In giant abdominal hernias this process is reversed, as the
viscera move into the peritoneal sac, the abdominal cavity
shrinks, the visceral content protrudes into a “container”, the
peritoneal sac. In these hernias the volume of intra- abdominal
viscera is reduced, and the intra-abdominal pressure adapts
consequently, gradually reducing the contractility of the
musculo-fascial structures, with a pronounced myofascial
retraction that worsens with time [1–4].
Hernias are not only defects in the abdominal wall but
are part of a whole pathological process which includes
respiratory, vascular and visceral dysfunction. Moreover,
they are frequently associated with obesity, chronic obstructive pulmonary disease, malnutrition, infection kidney and
heart disease, which are predisposing factors for their
development.
A.H. López, M.D., F.A.C.S. (*) • E.J.V. Rubalcava, M.D.
A.M. Zolezzi, M.D.
Department of General Surgery, The American British Cowdray
Hospital IAP, Mexico City, Distrito Federal, Mexico
e-mail: ady_hdezlopez@yahoo.com.mx;
draestefaniavillalobos@gmail.com; dradrianmurillo@gmail.com
45
When a patient has a giant hernia, changes in the
mesentery, bowel, skin and subcutaneous tissue occur.
Venous and lymphatic flow is reduced by compression from
the annulus. This causes an edematous, thickened and difficult to reduce mesentery.
The loss of domain caused by the lateral fascial muscle
retraction, the diaphragmatic relaxation and the frequent
association between hernias, obesity and cardiorespiratory
disease turns these patients into biologically and socially
handicapped individuals [5–8].
45.2 Loss of Domain, Definition
Loss of Domain is defined as a large hernia, with a diameter
of >10 cm or those whose contents of the hernia sack exceed
the capacity of the abdominal cavity; technically it is one in
which more than 50 % of the abdominal contents are located
outside of the abdominal cavity. Generally they take years to
form, the “giant” hernia sacs contain the viscera that can’t be
reduced because the abdominal cavity is no longer able to
accommodate them.
Mason defined them as those in which it was not possible to reintroduce the contents of the sac into the abdomen. He estimated a volume contained in the hernia sac of
over a litre or a diameter of the hernia ring exceeding
12 cm [9, 10].
Kingsnorth considers these hernias as those in which the
peritoneal sac has a volume of more than 15–20 % of the
natural volume of the abdominal cavity. He believes that if
the ratio of the volume of the hernia sac over the volume of
the abdominal cavity is less than 20 %, it is possible to perform a tension-free fascial closure.
According to Tanaka et al., the volume of the abdominal cavity is the main indicator of the loss of domain; it is easy to measure the volume of the abdominal cavity as is the volume of the
herniated viscera or hernia sac. If the ratio of the volume of the
sac over the volume of the abdominal cavity is greater than
25 %, it is considered a predictor for loss of domain [11–15].
© Springer International Publishing Switzerland 2017
W.W. Hope et al. (eds.), Textbook of Hernia, DOI 10.1007/978-3-319-43045-4_45
353
354
A.H. López et al.
45.3 Loss of Domain, Pathophysiology
Giant hernias occur through fascial defects that gradually
lose their domain in the abdominal cavity, with changes that
are “tolerated” because they develop gradually but will ultimately reduce the intra-abdominal pressure and the capacity
of the abdominal cavity.
The complexity of these patients lies in the loss of a functional abdominal cavity. There are pathophysiological
changes caused by maladjustment of multiple organ systems:
increased pressure causes decreased lymphatic and venous
portocaval return to the chest, there is vasodilation and venous
stasis in the abdomen, pelvis and lower limbs. Because of the
decreased venous and lymphatic return chronic edema occurs
in the omentum, mesentery and bowel. Friction exerted by the
ring on the bowel conditions inflammation that causes adhesions between loops of bowel, the sac and the hernia defect.
Intra-abdominal pressure decreases as more and more bowel
protrudes into the hernia sac; this causes decreased diaphragmatic excursion which lowers the strength of the diaphragm
and alters ventilatory physiology generating both an inspiratory and expiratory restriction [1–4, 11, 12].
45.4 Management of the Hernia with Loss
of Domain
dehiscence or altogether find himself unable to complete the
repair. We must bear in mind that these patients frequently
have concomitant diseases such as obesity, heart, or respiratory diseases which aggravate this situation [4, 12, 13, 18, 19].
To avoid this, it is imperative that adequate preparation
be performed, favouring the gradual rehabilitation of all systems, the reintroduction of visceral content into the abdominal cavity and the reconstruction of the abdominal wall.
45.5 Hernia Surgery with Loss of Domain
The use of prosthetic material in the repair of giant hernias is
associated with complications in 32 % of patients: infection,
enterocutaneous fistula, ileus, intestinal perforation, chronic
pain, abdominal rigidity, intestinal obstruction, foreign body
sensation and seroma. The quality of life of these patients is
inversely proportional to the size of the implanted mesh.
The effects of the myofascial retraction in these cases
influence the complexity of the wall repair. Current options
for hernia repair with closure under these conditions are: a
viable tissue bridge with permanent or biological prostheses,
tissue flaps with autologous fascia lata, rectus femoris or
latissimus dorsi and/or the use of tissue expanders and preoperative progressive pneumoperitoneum (PPP) [4, 20].
Loss of Domain implies that the abdominal contents are permanently found in the hernia sack (a second abdominal cavity).
These hernias are a challenge for the surgeon because of
the difficulty to replace the contents of the visceral sac into
the abdominal cavity. As the cavity, once emptied of its contents contracts, decreases in size, and is unable to accommodate the herniated viscera.
The forced reduction with primary closure can cause a devastating increase in intra-abdominal pressure which in turn
leads to a reduction in cardiac output because of a decrease in
venous return (preload) and an increase in peripheral vascular
resistance (afterload). There is an indirect reduction in myocardial contractility caused by a decrease in left ventricular adaptability. There is also a decrease in mesenteric and splanchnic
vascular flow; kidney function deteriorates as there is decreased
perfusion which leads to oliguria and azotemia; hormones such
as renin, which affects the systemic blood flow, are also released
which further worsen vascular dynamics [6, 9, 11, 16, 17].
The reduced thoracic volume and pressure exerted on the
diaphragm reduce the vital capacity that can lead to severe
respiratory failure with hypoxemia and hypercapnia which
further worsens diaphragmatic excursion leading to a reduction in venous return and hypertension.
An abdominal compartment syndrome ensues, causing
intestinal ischemia, respiratory distress, renal failure, skin
ischemia and/or necrosis. The surgeon might face hernia repair
45.6 Preoperative Progressive Pneumoperitoneum
Before the advent of anti-TB drugs, pneumoperitoneum was
used as a treatment for peritoneal tuberculosis.
In 1940, Goñi Moreno in Buenos Aires, Argentina, was the
first to report the use of preoperative pneumoperitoneum in
giant hernia repair. Goñi Moreno’s work was presented at the
American College of Surgeons in 1947. The reasoning behind
his idea was to allow the reintroduction of the abdominal viscera into the cavity, and their readaptation to the abdominal
cavity in a progressive fashion, reducing cardiovascular and
respiratory complications immediately after surgery.
The technique of preoperative progressive pneumoperitoneum described by Goñi Moreno allows a more physiological adaptation of the patient and the abdominal cavity to the
reintegration of the viscera into the abdomen, which favours
adequate surgical repair [1, 2, 8, 9, 12, 16].
45.7 Objectives of the PPP
It takes time to restore the abdominal capacity during the
PPP. One should perform abdominal CT scan to assess the
volume of the hernia. Measurements proposed by Tanaka
et al. confirm the loss of domain if the volume of the sac is
equal to the volume of the abdominal cavity. The tomo-
45 Progressive Preoperative Pneumoperitoneum (PPP)
355
graphic measurements should be done at the level of the third
lumbar vertebra, corresponding to the midpoint of the
abdominal cavity [11, 21, 22].
Transoperative pneumoperitoneum has been proposed to
have the same benefits of the PPP, it can reduce the degree of
visceral and mesenteric edema, it promotes lysis of adhesions
between the hernia ring and sac and allows easier identification of hidden defects. These benefits without a prolonged hospital stay [10], however, reduction of the herniated viscera is
only “temporarily” made possible by the muscle relaxing
effects of the general anaesthesia, which will afterwards return
to baseline with subsequent respiratory distress. These acute
changes can lead to atelectasia formation, hypovolemia, shock,
thrombophlebitis and thrombo-embólicos complications [3].
The objective of the PPP is to “gradually” stretch the
abdominal cavity with the concomitant increase in the length
of the abdominal wall muscles. It increases intra-abdominal
pressure gradually and improves diaphragmatic function,
which in turn improves ventilatory dynamics.
As the intra-abdominal pressure gradually increases,
there is a decrease in the thoracic compliance. The abdominal cavity progressively enlarges, and changes in the viscera
allow for the uneventful reintroduction of the herniated contents during the procedure.
45.8 PPP Physiology
Patients with hernias with loss of domain have low intraabdominal pressure. There is an imbalance between intraabdominal and thoracic pressure as a result with a resultant
weakened diaphragm, which leads to a lessened participation
of it in respiratory mechanics.
PPP acts in a way similar to pregnancy or accumulation of
ascitic fluid way: it expands the soft tissues of the abdominal
wall without causing sudden increase in intra-abdominal
pressure.
PPP causes distension of the musculo-fascial structures
and increases the volume of the once retracted abdominal
cavity. This happens with a subsequent elevation of the diaphragm which will resume its normal position once the
pneumoperitoneum is released. Although it has been documented that the vital capacity decreases in approximately
25 % (maximum reduction) during PPP, stretching the diaphragm improves subsequent post-operative respiratory
function. Pulmonary function tests performed immediately
after surgery show a vital capacity of 60–75 % of pre-PPP
values. This compares favourably with the 60 % reduction in
vital capacity observed during a routine cholecystectomy
during the first post-operative day [1, 7, 8, 19, 22].
With the elevation of the diaphragm and the lowering of
the pelvic floor during the PPP there is an increase in the
abdominal cavity volume. The turgidity of the herniated
organs is restored reducing their volume. This relaxation of
the abdominal wall promotes healing of any decubitus injury
caused by the herniated viscus [5].
The gradual increase in the capacity of the abdominal
cavity will allow for the intra-abdominal pressure to remain
low despite the contents being reintroduced into the cavity.
This results in improved diaphragmatic function and venous
return, especially relevant for patients with cardiopulmonary
co-morbidities who would otherwise have high risk of hemodynamic and respiratory complications.
Preparation of a patient with a giant hernia with PPP facilitates intraoperative dissection of the hernia sac and its contents due to the preoperative lysis of adhesions by the air.
The PPP acts as the conventional laparoscopic pneumoperitoneum, facilitating dissection of adhesions in an atraumatic way. Adhesions are stretched and enterolysis facilitated
unless these adhesions are firm and therefore do not allow for
the visceral reduction. This gradual pneumatic lysis of adhesions improves portal and mesenteric circulation and during
the procedure itself will facilitate dissection and reduction of
the herniated content [2, 3, 16].
It has been reported that the insufflation of air into the
abdomen fills not only the cavity, but also the hernia sac.
This prevents the sac from literally hanging and thereby
decreases chronic edema of the mesentery and other intraabdominal organs.
The effect of adherenciolisis explains the homogeneous
distribution of air through the abdominal cavity; interestingly, air distends the abdominal cavity more than it does the
hernia sac [1, 6, 9, 19].
The immediate result when performing the PPP is the distension of the hernia sac; however, over time the gradual
increase in the size of the abdominal cavity will be apparent.
As these changes transpire, the viscera return to the abdominal cavity, leaving the air filled sac over them and aided by
gravity. This is possible to see with a plain lateral decubitus
X-ray of the abdomen.
Another effect of pneumoperitoneum is increasing the
length of the abdominal wall muscles. Studies have been performed utilising CT scans of the abdomen which document
the effects of PPP in the size of the hernia and abdominal
musculature. They confirm that the PPP causes passive
stretching of the rectus abdominis muscles. Despite the longitudinal orientation of the rectus muscle the PPP increases
the amplitude and length of the musculature, exerting a similar effect on the hernia ring [12, 22].
Intermittent insufflation causes stretch of the muscle fibres.
Microscopic studies of muscle sections from experimental
studies show muscle dilation of all layers without hypertrophy
or hyperplasia. The effect is that of expansion and a reflex adaptation towards relaxation of the abdominal muscles. This expansion also causes areas of necrosis and lymphoid cell aggregates
along with a reactive inflammation of the peritoneum [14].